CAS E REP O R T Open Access Human immunodeficiency virus infection and autoimmune hepatitis during highly active anti-retroviral treatment: a case report and review of the literature Hanady Daas 1 , Riad Khatib 1* , Haitham Nasser 2 , Farah Kamran 3 , Martha Higgins 3 and Louis Saravolatz 1 Abstract Introduction: The emergence of hepatic injury in patients with human immunodeficiency virus infection during highly active therapy presents a diagnostic dilemma. It may represent treatment side effects or autoimmune disorders, such as autoimmune hepatitis, emerging during immune restoration. Case presentation: We present the case of a 42-year-old African-American woman with human immunodeficiency virus infection who presented to our emergency department with severe abdominal pain and was found to have autoimmune hepatitis. A review of the literature revealed 12 reported cases of autoimmune hepatitis in adults with human immunodeficiency virus infection, only three of whom were diagnosed after highly active anti-retroviral treatment was initiated. All four cases (inc luding our patient) were women, and one had a history of other autoimmune disorders. In our patient (the one patient case we are reporting), a liver biopsy revealed interface hepatitis, necrosis with lymphocytes and plasma cell infiltrates and variable degrees of fibrosis. All four cases required treatment with corticosteroids and/or other immune modulating agents and responded well. Conclusion: Our review suggests that autoimmune hepatitis is a rare disorder which usually develops in women about six to eight months after commencing highly active anti-retroviral treatment during the recovery of CD4 lymphocytes. It represents either re-emergence of a pre-existing condition that was unrecognized or a de novo manifestation during immune reconstitution. Introduction Impaired immunity in individuals with human immuno- deficiency virus (HIV) infection affects the defense mechanisms against pathogens and alters the regulation of autoimmunity [1]. This may lead to the emergence of autoimmune disorders or modification of pre-existing conditions. Several conditions may remit, such as sys- temic lupus erythematosus (SLE), while others, such as psoriasis, intensify. The development of liver disease during highly active anti-retroviral treatment (HAART) in patients with HIV infection without evidence of co- infection with hepatitis viruses poses a diagnostic dilemma. This may be due to treatment side effects or to the emergence of autoimmune disorders during immune restoration. Autoimmune hepatitis (AIH) is rare in patients with HIV infection. Additionally, hepatic involvement is unu- sual in other common autoimmune disorders. We pr e- sent the case of a patient w ith AIH and SLE emerging de novo during HAART a nd review all previously reported cases of AIH in patients with HIV infection who are undergoing HAART. Case presentation A 42-year-old African-American woman who had been diagnosed with HIV infection in 1989 acquired by het- erosexual contact had a fluctuating CD4 count and a viral load secondary to non-adherence. In March 2009, she was extensively counseled on adherence to treatment * Correspondence: Riad.Khatib@stjohn.org 1 Department of Internal Medicine, Division of Infectious Diseases, St John Hospital & Medical Center, 19251 Mack Avenue, Suite 340, Grosse Pointe Woods, MI 48236, USA Full list of author information is available at the end of the article Daas et al. Journal of Medical Case Reports 2011, 5:233 http://www.jmedicalcasereports.com/content/5/1/233 JOURNAL OF MEDICAL CASE REPORTS © 20 11 Daas et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the C reative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. and was started on a new regimen that included emtrici- tabine/tenofovir and etravirine. She became more com- pliant with treatment, and her clinical parameters improved. Before March 2009, her CD4 had b een 157 cells/mm 3 and her viral load had been 120,000 copies/ mL. One month after treatment adjustment, her CD4 went up to 232 cells/mm 3 and her viral load was unde- tectable. There was no personal or family history of auto- immune disease. Six months after treatment adjustment she started to experience gradual right upper quadrant pain associated with intermittent night sw eats. Her pain increased in intensity and became intractable. A computed tomo- graphic scan of her abdomen was unremarkable. She was seen in the office with fever and tachycardia and was hos- pitalized because of possible sepsis and acute abdomen. Her physical examination revealed that she was febrile (body temperature 102.1°F), tachycardic (130 b eats/m in) and hypoxic (O 2 saturation 84% on room air). Her chest examination revealed fine bibasilar crackles. Her abdom- inal examination demonstrated diffuse abdominal ten- derness with rebound that was most prominent in the right upper quadrant. A hepatobiliary iminodiacetic acid scan showed patent biliary ducts with a normal gallbladder ejection fraction. Computed to mography of the chest showed pericardial effusion that was confirmed by a transthoracic echocardiogram. On day 3 of her hospitalization, she underwent a peri- cardial window, a pericardial biopsy and a laparoscopy with liver biopsy. The l aparoscopy revealed a grossly abnormal liver (Figure 1). The liver biopsy demonstrated a dense portal lymphoplasmacytic infiltrate with multifo- cal zones of hepatocellular centrilobular necrosis consistent with AIH (Figure 2). Histologica l staining for fungi and mycobacterium were negative. Pertinent laboratory findingsinthispatientincluded alanine aminotransferase 1526 U/L, aspartate amino- transferase 777 U/L, international normalized ratio, 1.53; albumin level, 2.7 g/dL; anti-nuclear antibody (ANA) titer, 1:1280; negative anti-smooth muscle antibody; negative anti-cardiolipin and anti-ribosomal antibodies; anti-double-stranded DNA (anti-dsDNA) titer, 1:160; and immunoglobulin G level, 4600 mg/dL. Her antibo- dies to hepatitis viruses A, B and C and hepatitis B sur- face antigen were negative. Given her clinical picture, her positive laboratory test for ANA and anti- dsDNA and the histopathology of her liver biopsy, a diagnosis of SLE with AIH was made. Her calculated AIH score was 19 (> 15 is considered a definite diagnosis according to the International Autoimmune Hepatitis Group criteria). The patient was initiated on high-dose steroid therapy (40 mg every 12 hours). By the next day, her abdominal pain had improved, and she was discharged from the hospital on a tapering dose of steroids. One year after her hospitalization the patient remained in remission, with normal liver functi on and suppressed HIV viral load. Her steroid therapy was tapered off and stopped completely two months after being discharged from the hospital. Figure 1 Laparoscopic image of the liver showing diffuse whitish-gray plaque without nodularity or cirrhosis. Figure 2 Liver biopsy (hematoxylin and eosin stain) sho wing dense portal lymphoplasmacytic infiltrate and centrilobular hepatocellular necrosis caused by an acute chronic inflammatory infiltrate suggestive of autoimmune hepatitis. Daas et al. Journal of Medical Case Reports 2011, 5:233 http://www.jmedicalcasereports.com/content/5/1/233 Page 2 of 4 Discussion Our review of the literature revealed 12 cases of autoim- mune hepatitis in patients with HIV infection [2-8]. Three had co-infections with hepatitis C virus and were receiving interferon therapy [6-8] and six more had AIH before starting HAART and one pediatric patient’sdata were missing. Only three patients d eveloped AIH after starting HAART, similar to our patient. The clinical characteristics of the reviewed cases and our case are shown in Table 1. All patients who received HAART prior to AIH had a significant rise in CD4 count and undetectable HIV RNA before AIH was diagnosed. Two patients had other concomitant autoimmune diseases, one with Grave’s disease and the other with diffuse infil- trative lymphoc ytic syndrome. This review illustrat es that AIH in patients with HIV infection on HAART is rare. It has been encountered in women who had signif- icant elevations in CD4 count, suggesting the emergence of AIH during immune restoration. It presented insi- diously with non-specific manifestations. The diagnosis is usually based on AIH score, the absence of other con- ditions and characteristic histopathological findings. In patients who develop liver function abnormalities while receiving HAART, it is important to exclude drug-induced liver disease. In our patient, the pathogno- monic findings on the liver biop sy and the fact that she had been taking these medications long before she developed symptoms indicate that a drug reaction was not likely. The prognosis associated with AIH in patients with HIV infection appears to be variable based on a review of 11 out of the 12 reported cases (one reported case’s data were missing) of AIH in patients with HIV infec- tion. Two patients died while receiving interferon ther- apy for hepatitis C virus that triggered fulminant AIH, and o ne died as a result of severe Pneumocystis jiroveci pneumonia while receiving high-dose steroids for the treatment of AIH. Our patient had evidence of SLE in addition to AIH. Whether AIH is a manifestation of SLE or is unrelated is unclear. Liver involvement associated with AIH is relatively rare, ranging from 1.2% to 2% in patients with SLE who do not have HIV infection [9]. To date, it has not been reported simultaneously with SLE in patients with HIV infection. The precise mechanism causing the emergence or unmasking of autoimmune conditions in patients who are HIV-positive who commence anti-retroviral therapy is complex and involves multiple cytokines and lympho- cyte subsets [10-14]. Th17 cells have recently been implicated in association with chronic autoimmunity phenomena and especially in patients with HIV infec- tion and primates with simian immunodeficiency virus [10]. An a dditional subset of CD4 + regulatory T cells (Treg) has been described. It constitutively expresses CD25 and the transcription factor FoxP3 and has regu- latory functions [1]. Although the levels of Treg in patients who are HIV-positive with autoimmune mani- festations have not been reported, it seems plausible to propose that preferential depletion of Treg in some indi- viduals could account for the increased autoimmune phenomena in some patients with acquired immunodefi- ciency syndrome [15-18]. Conclusion The present case report and review of the literature describes a rare complication of immune restoration in patients with HIV infection in the era of HAART. Recognizing AIH in the context of immune reconstitu- tion and initiating appropriate therapy can be lifesaving. Treatment of these patients appears to be similar to that of patients without HIV infection. Table 1 Characteristics of 11 reported patients with concomitant HIV and AIH a Case reports Patient age (years)/gender Onset CD4 b /CD4 c VL b /VL c AIH score Outcome Other AI diseases ART German et al. [2] 38 d /man Chronic 216/384 81,000/< 50 Probable Excellent Vetilligo Yes Coriat and Podevin [7] 48/woman Acute 250 Undetectable Probable Died None Yes Puius et al. [3] 29/man Chronic 259/174 7122/27,732 Probable Excellent None Yes 45 d /woman Chronic 253/297 8687/< 50 Probable Excellent DILS Yes 65/woman Acute 200/922 Undetectable/< 75 Definite Excellent None Yes O’Leary et al. [4] 44 d /woman Chronic 269/526 4927/< 50 Definite Excellent Grave’s disease Yes Wan et al. [5] 56/man Chronic 331/NA 232,734/NA Probable Died None 54/man Chronic 357/213 5104/NA Probable Probable Cirrhosis Yes 55/woman Chronic 174/NA < 50/NA Probable Probable Poor Yes 49/woman Acute 286/NA 69,318/NA Definite Definite Died Yes Our patient 42 d /woman Acute 157/232 120,000/< 50 Definite Excellent SLE Yes a Two patients are not included because of lack of complete clinical data. HIV = human immunodeficiency virus; AIH = autoimmune hepatitis; AI, autoimmune; ART = antiretroviral treatment; VL = viral load; DILS = diffuse infiltrative lymphocytic syndrome; SLE = systemic lupus erythematosus; b prior to initiating highly active antiretroviral treatment (HAART); c after initiating HAART; d patients with significant viral suppression on HAART who developed AIH. Daas et al. Journal of Medical Case Reports 2011, 5:233 http://www.jmedicalcasereports.com/content/5/1/233 Page 3 of 4 Consent Written informed consent was obtained from the patient for publicatio n of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Abbreviations AIH: autoimmune hepatitis; HAART: highly active anti-retroviral therapy; HIV: human immunodeficiency virus; VL: viral load. Author details 1 Department of Internal Medicine, Division of Infectious Diseases, St John Hospital & Medical Center, 19251 Mack Avenue, Suite 340, Grosse Pointe Woods, MI 48236, USA. 2 Department of Pathology, St John Hospital & Medical Center, 22101 Moross Road, Detroit, MI 48236, USA. 3 Department of Internal Medicine, St John Hospital & Medical Center, 22101 Moross Road, Detroit, MI 48236, USA. Authors’ contributions HD wrote the manuscript, collected the images and obtained consent from the patient to publish this case report. RK reviewed the literature and edited the manuscript. FK coordinated care while this patient was hospitalized. LS provided inpatient care for the patient and edited the manuscript. HN reviewed and provided legends for the pathological images. MH reviewed the pathological specimens and made the initial diagnosis. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 29 September 2010 Accepted: 25 June 2011 Published: 25 June 2011 References 1. Elhed A, Unutmaz D: Th17 cells and HIV infection. Curr Opin HIV AIDS 2010, 5:146-150. 2. German V, Vassiloyanakopoulos A, Sampaziotis D, Giannakos G: Autoimmune hepatitis in an HIV infected patient that responded to antiretroviral therapy. Scand J Infect Dis 2005, 37:148-151. 3. 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Journal of Medical Case Reports 2011, 5:233 http://www.jmedicalcasereports.com/content/5/1/233 Page 4 of 4 . CAS E REP O R T Open Access Human immunodeficiency virus infection and autoimmune hepatitis during highly active anti-retroviral treatment: a case report and review of the literature Hanady Daas 1 ,. abdominal pain and was found to have autoimmune hepatitis. A review of the literature revealed 12 reported cases of autoimmune hepatitis in adults with human immunodeficiency virus infection, only. by a transthoracic echocardiogram. On day 3 of her hospitalization, she underwent a peri- cardial window, a pericardial biopsy and a laparoscopy with liver biopsy. The l aparoscopy revealed a